DS-4240-R

Request for Individual Access to Records Protected Under the Privacy Act
If you are seeking access to your records, please provide the U.S. Department of State this completed form. This form may also be used by a parent or guardian of a U.S. citizen or Lawful Permanent Resident seeking access to the records of a minor or a legal guardian seeking access to the records of an individual who has been declared by a court to be incompetent.